Advances in Gynecologic Oncology Surgery CME...2019/06/04 · Robotic-assisted surgery in...
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Advances in Gynecologic Oncology Surgery Lauren Krill MD, FACOG Assistant Professor OB/GYN & Oncology
Transcript of Advances in Gynecologic Oncology Surgery CME...2019/06/04 · Robotic-assisted surgery in...
Advances in Gynecologic Oncology Surgery
Lauren Krill MD, FACOGAssistant Professor OB/GYN & Oncology
Learner Objectives• Review new approaches in the surgical
management of gynecologic cancers• Discuss the management of high risk
individuals with uterine, cervical, and ovarian cancer
• Have fun and good discussion on hot topics in the literature!
Disclosures• In accordance with CME requirements I have
no relevant financial disclosures
Endometrial Cancer
Overview• Uterine cancer is the most common gyn
malignancy with over 60K new cases per year1
• Only 5, 000 of these cases are uterine sarcomas• However, usually symptomatic and thus
presents typically at early stages 2
– 70% are stage I at diagnosis – 5 year survival rate of stage I >95%– Mean age = 61; Only 8% are under age 45 – Incidence and mortality rates increasing
.
Treatment• Surgical staging :
– Total hysterectomy – Bilateral salpingo-oophorectomy– Visual evaluation of peritoneal, diaphragmatic,
serosal surfaces with biopsy as indicated– Lymph node dissection (pelvic +/- para-aortic)
• Open, laparoscopic or robotic approach acceptable– ***Fertility sparing: hormonal therapy – not standard but appropriate for
certain cases (ORR 77%)3
– Patients who are not candidates for surgery: Radiation
Presenter
Presentation Notes
Advances in technologies are driven by the pursuit of improved patient outcomes
Mode of Surgery• Open, laparoscopic or robotic approach: Data?• LAP2 Trial4
– Randomized controlled trial of open versus TLH– 3 year recurrence rate 11.4 vs 10.2% (NS)– 5 year OS 89.8% in both arms
• MIS supported and preferred for uterine confined disease by NCCN due to data demonstrating decrease infection, transfusion, VTE, LOS and lower cost of care, without compromise of oncologic outcomes5
Presenter
Presentation Notes
Over 2000 patients in this study, randomized 2:1. The first analysis demonstrated feasibility, safety, decreased morbidity and shorter recovery with better body image and QOL As far as oncologic outcomes the results demonstrated that laparoscopy was not inferior to TAH in terms of risk of recurrence and survival
Surgery for Endometrial Cancer • Robotic Surgery
– RCT data are lacking but supported by large observational studies and systematic reviews5
– Dutch study: National adoption of MIS showed Robotic MIS associated with decrease complications and improved survival compared to open surgery, no difference between robotics and conventional laparoscopy except decreased conversion rate6
– US studies indicated increased cost of Robotics>TLH, but decreased op time and more favorable learning curve, decreased conversion even with morbid obesity7
Presenter
Presentation Notes
Advances in technologies are driven by the pursuit of improved patient outcomes
Surgical Staging for Uterine Cancer • Historically-Staging practices have varied widely• Newest innovation is the introduction of Sentinel
Lymph Node Biopsy (SLNB)– Performed robotically or laparoscopy – May avoid total lymphadenectomy– Decrease risk of lymphedema and symptomatic lymphocyst
formation– Provide pathologic ultras-staging analysis (i.e. serial
sectioning and IHC to detect micrometastasis—upstages 5-15% of patients)
Presenter
Presentation Notes
Practice vary widely from universal staging to selective staging using frozen section and the Mayo Criteria to determine who to perform completely lymphadenectomy but this is associated with risks and is not in and off itself therapeutic, only prognostic. So is there a better way?
Surgery for Endometrial Cancer 5
• New advances : Sentinel lymph nodes
Presenter
Presentation Notes
This is a figure developed by MSKCC and depicts the injection sites which are done cervically and then then most common areas for mapping Indocyanine Green- is a fluorescent molecule which can be used with infrared camera or Firefly technology Which improved the detection rate and was found in several studies to be superior to blue dye
Robotic Sentinel Lymph Nodes
Example of Left External Iliac Lymph Node8
Surgery for Endometrial Cancer 5
SLNB Endometrial Cancer • FIRES trial –Clinical stage 1 EC 9
• Largest multicenter prospective study (n=385)• Sentinel-lymph-node mapping with complete
pelvic lymphadenectomy was performed Mapping of at least one SLN in 86%
• Sensitivity 97.2% • Negative Predictive Value was 99.6%• False Negative Rate 3%
Presenter
Presentation Notes
Total of 340 patients – 41 (12%) had node+ disease and 36 of these had SLN identified ---sensitivity for node+dz 97.2% and resulted in very high NPV Sentinel lymph node biopsy will not identify metastases in 3% of patients with node-positive disease, but has the potential to expose fewer patients to the morbidity of a complete lymphadenectomy. Now in the future what we need are prospective studies looking at +ITC and micromets
Cervical Cancer
Surgery for Cervical Cancer 10
• LACC• 5 stages of grief: Denial, Anger, Bargaining,
Depression…
Laparoscopic Approach to Cervical Cancer (LACC)10
• Randomized phase III non-inferiority trial of radical hysterectomy– Arm 1: minimal access surgery
(laparoscopic or robotic)– Arm 2: Open (laparotomy)
• Primary outcome: Disease Free Survival (DFS) at 4.5 years
• Secondary outcomes: recurrence rate, overall survival
Eligibility:• Squamous cell/ adenocarcinoma/
adenosquamous carcinomas of cervix
• FIGO stage 1A1 (+LVSI), 1A2-1B1• Planned type II or type III radical
hysterectomy• ECOG performance status 0-1
Laparoscopic Approach to Cervical Cancer (LACC) 10
• Treatment: • MIS: 319 patients • 84% laparoscopy• 16% robotic• Open: 312 patients • 92% both arms Stage IB1
• Results: • 4.5year DFS: 86% vs 96.5%• 3 year OS: 93.8% vs 99% • (HR=6; 95%CI 1.77)• MIS did NOT meetnon-inferiority criteria
Surgery for Cervical Cancer
• Minimally invasive radical hysterectomy was associated with a higher rate of recurrence and cancer related death than the open approach 10
Surgery for Cervical Cancer
• Reaction to LACC trial findings by Gyn Onccommunity: heavily debated and criticized
but it is level 1 evidence
• 5 stages of grief: Denial, Anger, Bargaining, Depression…
Surgery for Cervical Cancer • What now? Acceptance (and further testing)• NCCN guidelines (Version 4.2019)11
– Radical hysterectomy with BPLND (or SLNB) is the preferred treatment for early stage cervical cancer
– Standard and historical approach is open – Given recently presented findings of poorer survival
outcomes with MIS compared to open approach “women should be carefully counseled about the short and long-term outcomes and oncologic risk of the different surgical approaches.”
Presenter
Presentation Notes
MIS is no longer an acceptable alternative to open radical hysterectomy
Ovarian Cancer
Ovarian Cancer Management
• Role of surgery– Establish diagnosis– Comprehensive staging
Total hysterectomy/BSO OmentectomyLymph node dissection and staging biopsies
– Primary cytoreduction (debulking) removal of as much gross tumor as possible
Presenter
Presentation Notes
The best management of ovarian cancer primarily on the distribution of disease and whether or not they are likely to have optimal or complete cytoreduction, or not. The highest rates of survival have been consistently reported with complete cytoreduction to NGRD at primary debulking. However, this is not always feasible at the time of diagnosis.
Surgery for Ovarian Cancer • Recent data has been reported that has modified
treatment paradigm for ovarian cancer
• NCCN added an algorithm: poor surgical candidates and low likelihood of optimal cytoreduction12
• Randomized controlled trials of Neoadjuvant chemotherapy and interval debulk NOT INFERIOR to primary debulking surgery in select patients 13
(EORTC 55971 & CHORUS Trials)
Presenter
Presentation Notes
For example, if they had pleural effusions or otherwise stage IVB disease. Also, depends on their performance status and if they are medical compromised in some way that prohibits surgery or puts them at significant increased risk of morbidity (poor nutrition, alb <3). There is prospective randomized data that NACT is not inferior to primary debulking, It also increased chance of reaching NGRD at IDS, decreased need for bowel resections and postoperative complications (Median PFS 12 months in both, OS 30 vs 29 months, EORTC 55971). However, while I understand that cross trial comparisons are not scientifically valid many of these patients were recruited in Europe and it is difficult to asses the quality of debulking in this trial. Patients may or may not have had surgery with gyn oncologist, and rates of cytoreductive surgery were significantly lower than expected and the oncologic outcomes were inferior to what has previously been reported in several prospective RCT by GOG in the USA. Where the highest rates of survival have been consistently reported with complete cytoreduction to NGRD at primary debulking. Aware of these results and to emphasize that a patient with new diagnosis or suspected diagnosis of ovarian cancer should be seen by GYN ONC prior to therapy
THANK YOU
References1. American Cancer Society. Cancer Facts and Figures 2019. American Cancer Society. Cancer Facts & Figures
2019. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf. Published January 8, 2019. Accessed February 4, 2019.
2. National Cancer Institute. SEER Cancer Stat Facts: Uterine Cancer. https://seer.cancer.gov/statfacts/html/corp.html. Published April 2018. Accessed January 8, 2019
3. Gunderson CC, Fader AN, Bristow RE. Oncologic and reproductive outcomes with progestin therapy in women with endometrial hyperplasia and grade 1 adenocarcinoma: a systematic review. Obstet Gynecol2013; 121:1172-1180.
4. Walker JL, Piedmonte MR, Spirtos NM et al. Laparoscopy compared with laparotomy for comprehensive surgical staging uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009; 27 (32):5331-6.
5. NCCN Guidelines Version 3.2019 Uterine Neoplasms. Accessed June 1, 2019. www.nccn.org6. Jorgensen SL, et al. Survival after a nationwide introduction of robotic surgery in women with early-stage
endometrial cancer: a population-based prospective cohort study. Eur J Cancer 2019; 109: 1-11. 7. Sinno AK, Fader AN. Robotic-assisted surgery in gynecologic oncology. Fertil Steril 2014; 102:922-932. 8. Abu-Rustum NR. Sentinel lymph node mapping for endometrial cancer: a modern approach to surgical
staging. J Natl Compr Canc Netw. 2014 Feb; 12(2):288-97.9. Rossi et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging
(FIRES trial): a multicentre, prospective, cohort study. The Lancet Oncology 2017; 18(3):384-392.10. Ramirez P, Frumovitz M, Pareja R, et al. Minimally invasus versus abdominal radical hysterectomy for
cervical cancer. NEJM 2018; 379 (20): 1895-1904.11. NCCN Guidelines Version 4.2019 Cervical Cancer. Accessed June 1, 2019. www.nccn.org12. NCCN Guidelines Version 1.2019 Epithelial Ovarian Cancer. Accessed June 1, 2019. www.nccn.org13. Wright A, Bohlke E, Armstrong D, et al. Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian
cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline. Gynecologic Oncology 2016. http://dx.doi.org/10.1016/j.ygyno.2016.05.022
